What the health care system needs now

Do the rules of our health care system work anymore? That is the question posed in this column two weeks ago.

To answer this, let’s look back at the last 20 years. In 1986, Congress passed a very important law called EMTALA, the Emergency Medical Treatment and Active Labor Act. It aimed to stop “dumping,” the practice by some hospitals of refusing care to patients solely because they had no insurance. Enough cases of harm were assembled to convince Congress that dumping was bad. And it was, but then those hospitals were only playing by the rules. EMTALA changed the rules and much more. It requires Medicare-participating hospitals to provide a medical screening exam to anyone presenting to its emergency department regardless of ability to pay. The hospital must use whatever resources it has to determine if there is a medical emergency, and if so, to stabilize the person’s problem or transfer that person, if unable to stabilize them. As you might imagine, the law encompasses much more and the legal system has expanded its interpretation far beyond what was initially intended.

If you read the law, you will never find the feature that has had the most impact. Congress provided no funding. The health system just had to absorb the costs, and it did as much as it could. This was limited by Medicare funding under the DRG program, which fixed payments regardless of what it took to provide the service. As any good business would, it passed as much as it could of this cost to the people who actually paid the bills. Cost shifting, as it is called, assumed those who could pay would chip in more than their actual costs to help cover for those who could not pay.

Cost shifting was not new at the time; it was the de facto health care financing system. EMTALA merely accelerated it and caused an even larger disconnect between the actual cost of health care and what was charged for this care. Of even greater significance, this is the first time our federal government delved into universal health care, that’s right, and it happened way back in the 1980s. For the first time, any patient could get care in any emergency department, directed by our federal government. What was not fully appreciated at the time was that EMTALA is the biggest unfunded mandate ever created.

Jump to the mid-1990s. We had a national debate on how to finance health care. Stimulated by globalization, big companies felt less and less able to compete in the world market, while footing the bill for all this cost shifting. What we chose was managed care, which held out the prospect of controlling our health care spending. Private enterprise and the capitalist system would wring out the excess and drive innovation. We would treat health care as a business and subject it to the same tried and true methods that had propelled the US to become the only world superpower. But there were many in health care who were skeptical that health care could be reduced to widgets and commodities. And how were we to pay for all the unfunded care if the costs could no longer be shifted somewhere?

Growth of health care spending slowed — for a while. But now, 10 years later, spending is again on the rise. Although it forced the system to address its excesses, managed care also forced the system to reduce its capacity. We are now consumers, or clients, or associates, but whatever we are called, people were uncomfortable being told who they could see and when. Managed care’s answer was not well received.

That is now being addressed, as increasingly people have little or no choice. There are fewer hospital beds and not enough primary care doctors. Of great concern, both the American College of Physicians and the American Academy of Family Physicians released reports this year noting the need for more physicians in these specialties, while acknowledging that fewer medical students are choosing either one. Moreover, as the expenses and burdens mount and the reimbursements fall, doctors currently practicing in these specialities are getting out. This means less access to care, less capacity in the system, and as we age, fewer options where your health problems can be addressed. Your choice is being limited, not by planning, but by circumstance. This is certainly the reality if you are uninsured or receive Medicaid funding. But this is also becoming more of an issue even if you have insurance or Medicare. There are more people seeking care but less time to see them in, if you can be seen at all. There is simply less time to talk to people.

When there are no options, what choice does a person have? One may lament inappropriate emergency department visits, but EMTALA at least means there is some place to go. And we are still waiting to find out how we are going to pay for all the unfunded care.